Mentor Application/Recruitment Form
First Name(s):Last Name(s)
Job Title: Department:
Email: Telephone Ext:
Key academic & Professional Qualifications:
Please outline your reasons for wanting to be a mentor?
Have you trained/developed individuals in the past? Please be sure to highlight in particular any mentoring experience you have had.
Have you yourself received mentoring support?
Have you yourself received training?
Any further comments?
Date:
Signature:
Mentee Application Form
First Name(s):Last Name(s)
Job Title: Department:
Email: Telephone Ext:
Line Manager’s Name:
Academic subject areas:
Why do you want to join this programme? You may not have clearly identified your objectives yet, but it would be helpful if you could outline the general areas you are interested in.
Date:
Signature:
Mentoring Agreement
Name of mentee:Name of mentor:
Name of programme co-ordinator:
The purpose of the scheme
The scheme intends to match a person with relevant experience (the mentor) with a doctorwho can benefit from this experience (the mentee). The objective is to (state the objective of the scheme. If the objective requires the mentee to acquire specific types of knowledge, skill and/or experiences, you might want to list these here too).
The mentoring programme
New mentors and mentees will/may undergo an induction process which will outline the mentoring scheme with the programme coordinator. Profiles of mentors and mentees are used to match pairs. Mentees are given several options to choose from and preferences with regards to particular mentors are taken into account.
The mentoring relationships
In this scheme, mentoring is (specify nature of relationship, e.g. one-to-one?). They are expected to last for (specific duration of the relationships) and pairs are meant to meet on a (weekly/fortnightly/monthly/bi-monthly etc.) basis. The programme co-ordinator will manage the mentoring relationship. S/he is the first point of contact for mentors and mentees should there be any queries/problems.
The relationship is confidential and its content must not be discussed with any outside individuals. However doctors must always act in line with the good medical practice guidelines of the GMC should there be concerns about medical colleagues.
Within the relationship, the mentee is obliged to
(e.g. honour confidentiality and attend meetings regularly)
Within the relationship, the mentor is obliged to
(e.g. honour confidentiality and attend meetings regularly)
Signatures: If you have read and understood this agreement, please sign in the appropriate space below.
Signature: (Mentor) Date:
Signature: (Mentee) Date:
Signature: (Programme Coordinator) Date: